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Reimbursement summary for angioplasty of arteries of lower extremities

This post presents an extract from our reimbursement analysis for angioplasty of arteries lower extremities using plain and drug-coated balloons (DCBs) for peripheral artery disease in England, France and Germany. Plain balloon angioplasty is reimbursement via DRG solely and DCBs are reimbursement via combination of DRG and add-on reimbursement.
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New markers for pre-eclampsia and ovarian carcinoma included in EBM in Germany

In order to diagnose pre-eclampsia in pregnancy, two new markers were included in the EBM in early October 2019. The statutory health insurances then will take over the costs for the determination of the PIGF concentration and the sFlt-1 / PIGF quotient. In addition, another tumor marker for ovarian cancer will be included in the EBM.

The National Association of Statutory Health Insurance Physicians (KBV) and the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband) have agreed on the inclusion of three laboratory tests in the EBM (Einheitlicher Bewertungsmaβstab, German Uniform Evaluation Standard). It has been determined that the new pre-eclampsia markers will be reimbursed extrabudgetary for a period of two years.

Pre-eclampsia, the hypertensive pregnancy disease, affects about 2% of all pregnant women and is the leading cause of maternal and perinatal morbidity and mortality. If the symptoms are unclear, the markers provide objective decision support for further outpatient or, if necessary, early inpatient monitoring of the pregnant women.

For the determination of the placental growth factor (PIGF) concentration, the decrease of which indicates a malfunction of the placenta and thus represents an essential indication of pre-eclampsia, the fee order item (GOP) 32362 (€19.40) will be included in the EBM. The determination of the sFlt-1 / PIGF quotient allows excluding the doubtful pre-eclampsia with a high probability for a period of four weeks. This requires two separate analyzes. The doctors can calculate these with the GOP 32363 (€62.25).

The Evaluation Committee has also determined in which cases pre-eclampsia markers may be calculated: there must be a fetal growth disorder, or a newly occurring or existing hypertension diagnosed in mother. The examination may also be indicated for other organic or laboratory diagnostic findings associated with pre-eclampsia that cannot be explained by any other cause, or a suspicious Doppler ultrasound finding.

The both GOPs 32362 and 32363 cannot be billed more than three times in the treatment case and cannot be charged together on the same day of treatment. Reimbursement for the new benefits will be provided outside morbidity-related total remuneration (morbiditätsbedingen Gesamtvergütung, MGV). At the end of the two-year period, they will be transferred to MGV if the volume trend will not require further extra-budgetary reimbursement.

With the same decision, the tumor marker HE 4 was included in the EBM catalog. This marker has comparable properties in the diagnosis of primary and recurrent ovarian cancer with the previously listed under the GOP 32390 marker CA 125. Therefore, HE 4 was integrated into this GOP and is billed from October 1, via the GOP 32390 (€10.60).

The full details in German can be found here.

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